Carcinoma Of Pancreas Symptoms

Carcinoma Of Pancreas

Carcinoma Of Pancreas Introduction

• 70% of the cases occur in the head of the pancreas including periampullary region.
• 30% occur in the body and the tail.
• 70% of cases are adenocarcinoma of duct cell origin.
• It is 4th leading cause of death due to cancer in males, after lung, colon, prostate.

Aetiology

• Chronic tropical pancreatitis and hereditary pan-creatitis are associated with pancreatic cancer—such malignancies can be multifocal.
• Haemochromatosis produces extensive calcification of pancreas. It is also a precancerous condition.
• Diabetes: Diabetic patients are 10 times more vulnerable to develop carcinoma of pancreas.
• Other possible aetiological factors
  • Alcohol and smoking: It is related to tobacco specific nitrosamines (including smokeless tobacco).
  • Westernisation of diet: Fatty food, rich in animal proteins can cause pancreatic cancer.
  • Industrial carcinogens: B11-naphthylamine, benzidine, gasoline are the possible agents.

Pathology: Periampullary refers to carcinoma arising from ampulla of Vater, the duodenal mucosa or the lower end of the common bile duct.

Microscopically, the types are:

1. Mucus-secreting carcinoma of ductal origin.
2. Nonmucus-secreting carcinoma of acinar origin.
3. Anaplastic carcinomas are poorly differentiated and tend to arise from the body of the pancreas.
4. Cystadenocarcinomas are rare, slow-growing and tend to attain a large size.

Carcinoma Of Pancreas Clinical Features

• Periampullary and carcinoma head of pancreas present as obstructive jaundice (discussed already). Discussion here is on carcinoma body and tail of pancreas.
• Microscopically, the tumour shows malignant cells with a variable degree of differentiation, mitotic figures, etc. Not only it invades vessels and lymphatics, but also perineural spread occurs fast which explains backache.

Carcinoma Of Pancreas Symptoms

• Severe pain radiating to the back in the region of L1 and L2. It is due to infiltration of retroperitoneal nerve plexuses or pancreatic duct obstruction.
• Pain is so severe, often patient requests for narcotic analgesics.
• Gross weight loss in 3-6 months.
• Anorexia, asthenia and generalised weakness.
• Jaundice cannot occur in carcinoma body and tail of pancreas unless there are secondaries in liver or lymph nodes at porta hepatis.
• Symptoms of vomiting suggest duodenal obstruction.
• Trousseau’s sign (thrombophlebitis migrans):
  • Migrating thrombophlebitis of the legs can occur in visceral malignancies particularly from carcinoma of pancreas, rarely carcinoma stomach, colon, etc.
  • It is supposedly due to sluggish blood flow resulting in thrombus formation.
  • It is superficial and affects the leg veins, such as long saphenous vein.

Carcinoma Of Pancreas Signs

• Anaemia may be present as in any other malignancy.
• Jaundice is not a feature. Left supraclavicular node may be palpable.
• Per abdomen findings: Majority of these cases are advanced, fixed and are felt as a mass in the upper abdomen.

1. Characteristics of a pancreatic mass
   • It is situated on the left side involving left hypo- chondrium, umbilical region and epigastrium.
   • It does not move with respiration because it is retroperitoneal.
   • Trousseau’s sign is also found in Buerger’s disease
   • It does not fall forwards in knee elbow position.
   • Can get above the swelling.
   • On percussion, it gives a resonant note because of anterior position of stomach.
2. Features of carcinoma
   • It is common in elderly, male patients smokers.
   • Hard, irregular, fixed lump.
   • Significant weight loss +.
3. Evidence of metastasis: Secondaries in the liver, ascites, rectovesical deposits.

Differential Diagnosis

1. Carcinoma stomach infiltrating the pancreas
   • Such mass may not be mobile. It does not move with respiration because it is fixed to pancreas.
   • These patients will have vomiting first followed by backache at a later date.
2. Carcinoma transverse colon: Produces constipation and bleeding per rectum. Vertical mobility may be present. Right to left peristalsis may be present.
3. Para-aortic lymph node mass may be due to: Intra-abdominal malignancies, lymphoma, testicular tumour, etc.

Carcinoma Of Pancreas Investigations

1. Investigations for periampullary carcinoma and carcinoma of head of pancreas (discussed before).
2. Investigations for carcinoma of body and tail (discussed here)

1. USG: First investigation of choice

• Rules out calculous obstruction
• Can detect a mass as small as 2 cm
• Intraoperative ultrasound can be used to take a biopsy.

2. Contrast-enhanced CT scan

• Retroperitoneal invasion
• Lymph node enlargement
• Invasion of hepatic artery, superior mesenteric artery, ascites, liver metastasis—unresectable.
• Infiltration of portal vein which makes it inoperable
• In more than 70% of cases, pancreatic duct is dilated and in more than 60% of cases bile duct is dilated.
• When both these ducts are dilated, it is most likely pancreatic cancer.
• CT-guided aspiration biopsy is indicated for lesions to start neoadjuvant chemotherapy/RT (infiltrative lesions).

3. ERCP is indicated in the absence of a mass. Findings can be stenosis/obstruction.

4. Carbohydrate antigen CA 19-9: These are glyco-proteins which are elaborated by malignancies. It is a tumour marker of pancreas to monitor carcinoma pancreas. Increased in 75% of patients with carcinoma pancreas and 10% of the patients in benign disease of pancreas, liver and bile ducts. Hence, it is not a diagnostic investigation. However, very high values suggest malignancy even when histology is inconclusive.

Carcinoma Of Pancreas Treatment

• Periampullary carcinoma—Whipple’s operation
• Carcinoma of body and tail
• If the tumour is very small and diagnosed very early, they are ideally treated with total pancreatectomy with removal of involved lymph nodes.
• Many cases are diagnosed late. They are inoperable either due to fixity to portal vein or due to metastasis. Hence, there is no role for curative surgery. For the confirmation of diagnosis, transabdominal USG- guided fine needle aspiration cytology can be done. Surgery is not indicated in such cases; only palliative treatment can be offered. Prognosis is very poor.
  • Palliative radiotherapy: 4000-6000 cGy units can be given. Response rate is 5-10%. It reduces size of the tumour and some pain relief is obtained.
  • Palliative treatment is an important aspect of carcinoma pancreas even though such patients succumb to the disease within 3 to 6 months. Palliation is mainly to relieve pain.

True Cystic Pancreatic Neoplasms (CPNs)

These are uncommon tumours present predomi¬nantly in women. Other rare tumours are cystadenocarcinoma, acinar cell cystadenocarcinoma, etc.

• These tumours can be confused with pseudocyst of the pancreas. Hence, they should be differentiated at surgery. Otherwise, gross blunders can take place.
• Serous and mucinous are important. They are discussed in Table.

True Cystic Pancreatic Neoplasms (CPNs)

• Serous cystadenoma Benign: Common in women, located in head of pancreas. They account for 30% of all CPNs. They can be observed, if asymptomatic.
• Mucinous cystic neoplasms (MCNs)
  • More common in women
  • More often found in body and tail
  • More incidence than serous (40%)
  • Considered premalignant
  • Do not communicate with ductal system
  • Lesions more than 2 cm need to be resected
    
• Intraductal papillary mucinous tumours (IPMTs)
  • Slightly more common in males
  • Communicates with duct
  • Incidence is about 25%
  • High malignant potential
  • More common in head involving ampulla of Vater
  • Treated by Whipple’s resectio